VA takes a leap of faith into telehealth

The Veterans Affairs Department is already a step ahead of the rest of the federal government in promoting telehealth, also called telemedicine. Now VA is jumping forward again by proposing to double its telehealth investment over two years.

VA’s home telehealth program cares for 35,000 patients and is the largest of its kind in the world. According to the department's plans, it would grow to $163 million in fiscal 2011, more than twice the $72 million spent in fiscal 2009.

But without a broader federal strategy, VA’s leap into telehealth is, to some degree, a leap of faith.

It’s not that VA has gone too far; rather, other federal agencies possibly have not gone far enough. Federal policy-makers have not yet taken a comprehensive look at this technology. The government’s approach has been piecemeal, with various programs initiated for payers, providers and regulators. Federal regulations and reimbursements for telehealth practices are not cohesive, said Jonathan Linkous, executive director of the American Telemedicine Association.

“In telehealth, the federal government needs to educate, coordinate and get out of the way,” Linkous said.

Telehealth, defined broadly as the electronic communication of medical data as a means for providing care to a patient, has been around for decades. It includes the use of phones, computers and other devices, with or without video or images, to allow patients in remote locations to consult with medical specialists.

Advocates say telehealth is cost-efficient and improves care. “You can lower costs, improve outcomes and expand access to care,” said Dr. S. Ward Casscells, former assistant secretary of Defense for health affairs and a practitioner of telehealth.

VA, the Indian Health Service and the Defense Department all offer some telehealth services, as do many hospitals and clinics. Last year’s economic stimulus package set aside $7 billion for broadband, a portion of which will be devoted to rural telemedicine.

Because of that stimulus and federal programs, Timothy Deal, senior analyst at research firm Pike & Fischer, forecasts the U.S. telemedicine market will reach $3.6 billion by 2014, up from $855 million in 2009.

One area in which VA and others have advanced telehealth is in mental health. Training and protocols for online psychological practice are well-established, said Marlene Maheu, a clinical psychologist in San Diego who leads the Telemental Health Institute. “Telehealth is more research-based than many other forms of medicine,” she said. However, she cautioned that the Internet is spawning new types of clinics that purport to offer telehealth services that might not conform to protocols.

Although telehealth holds much promise, adoption has been hampered by potential legal liabilities, difficulties in receiving reimbursements for care delivered remotely, and legal complications regarding telemedicine practices that cross state lines.

Critics also worry about possible negative effects on patient care. VA’s inspector general recently investigated two deaths at a Colorado VA hospital that occurred while the patients were being monitored by cardiac telemetry, a form of telemedicine. “We substantiated the allegation that there were competency and training issues with medical support assistants and registered nurses assigned to telemetry,” the IG wrote in the report dated Jan. 21. The report also notes that hospital managers had been informed of the telemetry problems before the deaths but had taken no action.

VA managers agreed to evaluate the telemetry program in Colorado to ensure safety, and Linkous and Casscells said it was likely an isolated incident. However, more of the same can be expected, Deal predicts. “The rapid growth of the telemedicine industry will leave gaps in training and/or policy among its practitioners, which could spark an increase in litigation,” he said.

VA’s foray into telehealth could be a life-saver for some patients in remote areas who otherwise would not receive timely care.  But it also carries risks. “If the transition from legacy services to modern ones disrupts patient care, I expect to see some patient backlash,” Deal said. "There will be growing pains, and people need to understand this."

If telehealth expands dramatically at VA, it should happen within a broader context. The time is ripe for VA, DOD and the Health and Human Services Department to work together on a telehealth strategy.